Universal Free School Meals and School and Student Outcomes

Key Points Question What is the association between universal free school meals (UFSMs) and school and student outcomes in US schools? Findings In this systematic review of 6 studies comprising more than 11 000 schools, implementation of UFSM was associated with increased lunch (3 studies) and breakfast (1 study) participation, no change or modestly improved attendance (2 studies), and decreased obesity prevalence (1 study) and suspensions (1 study). The association with lunch participation had a moderate certainty of evidence, while the other associations had low or very low certainty of evidence. Meaning In this study, implementation of UFSMs was associated with increased meal participation and potentially increased attendance and decreased obesity and suspensions.

The records were uploaded to DistillerSR, an online software used for literature management that enables reviewers to complete all stages of an SR independently.Two independent reviewers used the predetermined inclusion and exclusion criteria to first screen titles and abstracts, followed by full text screening of records included from the first-level screen.Any conflicting decisions were either resolved through a discussion between the two reviewers, or when appropriate, by another reviewer.Reasons for full text exclusions are provided in supplementary table 2.

D. Data Extraction
Study characteristics included study design, school level (elementary, middle, or high school), location, cohort name if applicable, school year(s), sample size, meal (breakfast and/or lunch), participation rates of the intervention, and the comparator involved in the study.The extracted participant data included sex, age, and race/ethnicity of the child, child's or parental socioeconomic status, and participation status for other US federal assistant programs (i.e.SNAP).Quantitative results between universal free school meals and outcomes of interests were extracted for each included article.Predetermined key confounding variables that studies did or did not consider were noted, in addition to other confounding factors assessed (figure 1).Reviewers noted limitations they identified and those listed in each study.For each included article, data were extracted by a reviewer, then the extracted data was verified for accuracy and completeness by a second reviewer.In the case of discrepancies between reviewers, conflicts were resolved through discussion or by input from a third reviewer.

E. Risk of Bias
The risk of bias (ROB) of each included article was assessed independently by two reviewers.To assess nonrandomized studies of interventions (NRSI), Cochrane's Risk Of Bias In Non-randomized Studies -of Interventions (ROBINS-I) tool was used, which evaluates ROB for confounding, selection of participants, classification of interventions, deviation from the intended intervention, missing data, measurement of outcomes, and selection of the reported results. 3The ROB for each domain was determined to be low, moderate, serious, critical, or no information.
The overall study ROB rating was equivalent to the most severe ROB rating of any of the seven domain levels.Any disagreements in ROB rating at the domain and overall level were resolved between the two reviewers through discussion or if necessary, by another researcher.

F. Grading Certainty of Evidence
The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence for each main finding.GRADE can be used for NRSIs, particularly when evidence from randomized studies is unavailable or not feasible. 4GRADE provides a certainty of evidence rating by outcome and study design across the evidence. 4For RCTs and NRSIs that are assessed using Cochrane ROB tools, the GRADE starts as high and is downgraded for every downgrade from the following domains: ROB, inconsistency, indirectness, imprecision, and publication bias.For NRSIs, ratings can be upgraded for each upgrade from: magnitude of effects, influence of all plausible residual confounding, and dose-response gradient.Overall, each outcome could be graded to have high, moderate, low, or very low level of certainty. 4Two reviewers independently used GRADE to analyze the certainty of evidence, and consensus on decisions was reached through discussion or by the input of a third reviewer.
List of Studies Excluded at the Full Text Level, With Reason for Exclusion TI((universal or free) n2 (meal or lunch)) OR AB ((universal or free) n2 (meal or lunch)) or TI ("National School Lunch" or "free or reducedprice meals") or AB ("National School Lunch" or "free or reducedprice meals") or TI ("Community Eligibility " ) or AB ("Community Eligibility " ) AB (meal* or lunch* or breakfast*) or TI (meal* or lunch* or breakfast*) © 2024 Spill MK et al.JAMA Network Open.NA © 2024 Spill MK et al.JAMA Network Open.